A Nursing Development Strategy for Bangladesh

2. Compared even to other Lower Middle-Income Countries [LMIC], Bangladesh has fewer health care workers of all kinds. For nursing, this shortage is made worse by the low level of skills among registered nurses. Many factors cause this competency problem: low skill level of nurse educators with few opportunities for professional development; lack of practicum sites where student nurses observe good practice; weak approval processes for nursing colleges. Other context problems include weak professional regulation; physician resistance to advancement of nurses; and unlicensed and untrained workers calling themselves nurses.

3. Improving the nurse situation in Bangladesh is not a new idea. During the past 25 years, international donors have invested substantially in programs to "strengthen nursing in Bangladesh". (Our conservative estimate is over $50 million USD. The results have been disappointing, partly due to implementation challenges, such as the clinical practice environment, internal resistance and malfeasance. There have also been donor mis-steps due to importation of "Western" approaches: BSN entry-to-practice is expensive; assumptions about governance have been unrealistic; the focus on hospital care neglects primary or universal health care which could benefit more Bangladeshis.

4. Despite nearly three decades of external support, nurse-to-population ratios are not much improved. The incessant effect of brain drain is like pouring water into a bath-tub with no stopper plug. It seems unlikely that donors will again commit this level of external support to help Bangladesh fix its health care system, particularly if the internal problems persist.

5. On a positive note, there exists today a better understanding of both the potential contribution of nurses and the opportunities for good jobs here and abroad. For several years government policy has promoted nurse emigration. This has resulted in strong demand for nurse education, despite its generally poor quality. The downside is that we can expect thousands of unemployable nursing graduates in the next few years: unable to pass qualifying exams overseas, yet lacking primary health care skills to serve the national population.

6. From a population health perspective, the last two decades have been a missed opportunity. Bangladesh has been identified as an LMIC with above-average burden of non-communicable diseases, pandemic risks and antimicrobial resistance. These national problems will be intensified by global impacts such as climate change and economic shocks. The situation requires urgent and focused strategy to reduce the impact.